BSN 246 HESI Health Assessment Exam V2
(Latest 2025/ 2026 Update) Questions and
Verified Answers |100% Correct| Grade A-
Nightingale
In observing a client's face, which assessment finding requires the
most immediate intervention by the nurse?
A. Oral mucosa is cyanotic.
B. Nasolabial folds present bilaterally
C. Smooth and even skin tone
D. Absence of facial drooping
A. Oral mucosa is cyanotic.
While obtaining a health history, a male client tells the nurse that he
sometimes experiences shortness of breath. The nurse determines
that the client's respirators are regular and deep, and his respiratory
rate is 14 breaths/minutes. What is the best nursing action?
A. Administer oxygen immediately.
B. Ask the client to describe the episodes of dyspnea in more detail.
C. Notify the healthcare provider about the client's condition.
D. Place the client in a prone position to ease breathing.
B. Ask the client to describe the episodes of dyspnea in more detail.
When assessing a male client's respiratory status, which technique
should the nurse use to assess his anterior-posterior (AP) chest
diameter?
,A. Intervention.
B. Assessment.
C. Documentation.
D. Observation.
D. Observation.
Which assessment finding supports the client's statement, "My feet
swell all the time?"
A. No edema present.
B. 2+ pitting edema of ankles bilaterally.
C. Non-pitting edema of the lower extremities.
D. Redness and warmth in the ankles.
B. 2+ pitting edema of ankles bilaterally.
The nurse is performing a cranial nerve exam on an 87-year-
old client. The nurse notes that the client has a reduced upward gaze,
a decreased corneal reflex, a high-frequency hearing loss, and a
reduced gag reflex. What action should the nurse take next?
A. Repeat the cranial nerve test to confirm the findings.
B. Document the findings and notify the healthcare provider.
C. Ask the client if they are experiencing any unusual symptoms.
D. Continue the assessment to the next pairs of cranial nerves.
D. Continue the assessment to the next pairs of cranial nerves.
When performing a neurologic assessment on an alert client, the
nurse observes that the client's pupils are both round, 3 mm in size,
and respond briskly to light. Which notation should the nurse use
when documenting the assessment
A. PERRL
, B. Dilated pupils
C. Unequal pupil size
D. Sluggish pupillary reaction?
A. PERRL
Which assessment technique provides the nurse with the best data
related to the client's level of peripheral perfusion?
.
The nurse is assessing a female client who states that her hemorrhoids
are inflamed and hurt constantly. Which intervention is best for the
nurse to complete a focused assessment?
A. Position the client in the left lateral position to inspect the perianal
area for fissures or sacs.
B. Palpate the perianal area with both hands to assess skin elasticity.
C. Ask the client to stand and bend forward to assess the sacrum.
D. Apply deep palpation to the lower abdomen to detect tenderness.
A. Position the client in the left lateral position to inspect the perianal
area for fissures or sacs.
The nurse is performing an initial assessment of a client who has an
expressionless facial affect, slurred speech, and red conjunctivae.
What question should the nurse ask first?
A. "Have you been sleeping well?"
B. "What did you eat for breakfast today?"
C. "Do you experience any changes in your vision?"
D. "How often do you exercise during the week?"
A. "Have you been sleeping well?"
(Latest 2025/ 2026 Update) Questions and
Verified Answers |100% Correct| Grade A-
Nightingale
In observing a client's face, which assessment finding requires the
most immediate intervention by the nurse?
A. Oral mucosa is cyanotic.
B. Nasolabial folds present bilaterally
C. Smooth and even skin tone
D. Absence of facial drooping
A. Oral mucosa is cyanotic.
While obtaining a health history, a male client tells the nurse that he
sometimes experiences shortness of breath. The nurse determines
that the client's respirators are regular and deep, and his respiratory
rate is 14 breaths/minutes. What is the best nursing action?
A. Administer oxygen immediately.
B. Ask the client to describe the episodes of dyspnea in more detail.
C. Notify the healthcare provider about the client's condition.
D. Place the client in a prone position to ease breathing.
B. Ask the client to describe the episodes of dyspnea in more detail.
When assessing a male client's respiratory status, which technique
should the nurse use to assess his anterior-posterior (AP) chest
diameter?
,A. Intervention.
B. Assessment.
C. Documentation.
D. Observation.
D. Observation.
Which assessment finding supports the client's statement, "My feet
swell all the time?"
A. No edema present.
B. 2+ pitting edema of ankles bilaterally.
C. Non-pitting edema of the lower extremities.
D. Redness and warmth in the ankles.
B. 2+ pitting edema of ankles bilaterally.
The nurse is performing a cranial nerve exam on an 87-year-
old client. The nurse notes that the client has a reduced upward gaze,
a decreased corneal reflex, a high-frequency hearing loss, and a
reduced gag reflex. What action should the nurse take next?
A. Repeat the cranial nerve test to confirm the findings.
B. Document the findings and notify the healthcare provider.
C. Ask the client if they are experiencing any unusual symptoms.
D. Continue the assessment to the next pairs of cranial nerves.
D. Continue the assessment to the next pairs of cranial nerves.
When performing a neurologic assessment on an alert client, the
nurse observes that the client's pupils are both round, 3 mm in size,
and respond briskly to light. Which notation should the nurse use
when documenting the assessment
A. PERRL
, B. Dilated pupils
C. Unequal pupil size
D. Sluggish pupillary reaction?
A. PERRL
Which assessment technique provides the nurse with the best data
related to the client's level of peripheral perfusion?
.
The nurse is assessing a female client who states that her hemorrhoids
are inflamed and hurt constantly. Which intervention is best for the
nurse to complete a focused assessment?
A. Position the client in the left lateral position to inspect the perianal
area for fissures or sacs.
B. Palpate the perianal area with both hands to assess skin elasticity.
C. Ask the client to stand and bend forward to assess the sacrum.
D. Apply deep palpation to the lower abdomen to detect tenderness.
A. Position the client in the left lateral position to inspect the perianal
area for fissures or sacs.
The nurse is performing an initial assessment of a client who has an
expressionless facial affect, slurred speech, and red conjunctivae.
What question should the nurse ask first?
A. "Have you been sleeping well?"
B. "What did you eat for breakfast today?"
C. "Do you experience any changes in your vision?"
D. "How often do you exercise during the week?"
A. "Have you been sleeping well?"
